ACH Recurring Payment Authorization Form

Name *

First

Last

Email *

Confirm Email

Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Account Type *

Personal Checking
Personal Savings
Business Checking
Business Savings

Preferred Day of Draft *

On what day of the month would you like to pay?

Name on Account *

Bank Name *

Account Number *

Bank Routing Number *

Bank City/State *

Signature *

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify CPLIC Member Services, LLC in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that CPLIC Member Services, LLC may at its discretion attempt to process the charge again within 30 days, and agree to an additional $30 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.

Date *

By completing this form, I authorize CPLIC, RRG to charge my bank account each month on the day indicated below for payment of my policy premium as quoted. Data submitted from this form is securely transmitted and will only be used to connect for payment processes. All information is held confidential and will not be stored past the time needed for processing.

Schedule your payment to be automatically deducted from your checking or savings account. Just complete, sign and return the form, on this page, to get started!

Recurring Payments Will Make Your Life Easier:

It’s convenient, saves you time and/or postage
Your payment is always on time, eliminating late charges
Secure, easy to track and receive immediate confirmation of payment

Here’s How It Works:

You authorize regularly scheduled charges to your checking or savings account. You will be charged the amount indicated on your quote for each billing period. A receipt for each payment will be emailed to you and the charge will appear on your bank statement as an “ACH Debit.” You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected. A down payment of at least 20% is required to get started and can be paid separately online at www.cplic.net/pay-now.

Where are my routing and bank account numbers?

You can find these numbers on your checks, as follows:

ACH Recurring Payment Authorization Form

Latest News